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Psychological Factors, Including Alexithymia, in the

Prediction of Cardiovascular Risk in HIV Infected


Patients: Results of a Cohort Study
Giustino Parruti1*., Francesco Vadini1., Federica Sozio1, Elena Mazzott1, Tamara Ursini1, Ennio Polill1,
Paola Di Stefano1, Monica Tontodonati1, Maria C. Verrocchio2, Mario Fulcheri2, Giulio Calella1,
Francesca Santilli3, Lamberto Manzoli4
1 Unit of Infectious Diseases, Pescara General Hospital, Pescara, Italy, 2 Clinical Psychology Division, University of Chieti-Pescara, Italy, 3 Department of Medicine and
Aging, University of Chieti-Pescara, Italy, 4 Section of Hygiene, Epidemiology, Pharmacology and Legal Medicine, University of Chieti-Pescara, Italy

Abstract
Background: Psychological factors are known predictors of cardiovascular disease in many clinical settings, but data are
lacking for HIV infection. We carried out a prospective cohort study to evaluate potential psychological predictors of
preclinical and clinical vascular disease in HIV patients.
Methodology/Principal Findings: HIV patients were consecutively enrolled. Demographics, viral and immune parameters
and traditional cardiovascular predictors were considered; Intima-Media Thickness (c-IMT, continuous measure) and Carotid
Plaques (CPs, focal thickening $1.5 mm) were investigated by B-mode ultrasonography; depressive symptoms by the Beck
Depression Inventory (BDI-II), Type D personality (Distressed Personality or Type D) by the DS14, alexithymia by the Toronto
Alexithymia Scale (TAS-20). Vascular outcomes included transient ischemic attacks or stroke, acute coronary syndrome,
myocardial or other organ infarction. We enrolled 232 HIV subjects, 73.9% males, aged 44.569.9 y, 38.2% with AIDS
diagnosis, 18.3% untreated. Mean Nadir CD4 T-cell counts were 237.56186.2/mmc. Of them, 224 (96.5%) attended IMT
measurements; 201 (86.6%) attended both IMT assessment and psychological profiling. Mean follow-up was 7826308 days.
Fifty-nine patients (29.4%) had CPs at baseline. Nineteen patients (9.5%) had $1 vascular event; 12 (6.0%) died due to such
events (n = 4) or any cause. At baseline cross-sectional multivariate analysis, increasing age, total cholesterol, current
smoking and Alexithymia score$50 were significantly associated with both increased cIMT (linear regression) and CPs
(logistic regression). At follow-up analysis, log-rank tests and Coxs regression revealed that only older age (p = 0.001),
current smoking (p = 0.019) and alexithymia score$50 (p = 0.013) were independently associated with vascular events.
Conclusions/Significance: In HIV-infected subjects, the Alexithymic trait emerges as a strong predictor of increased IMT,
presence of CPs and vascular events. Such results are preliminary and require confirmation from studies with larger sample
size and longer follow-up.
Citation: Parruti G, Vadini F, Sozio F, Mazzott E, Ursini T, et al. (2013) Psychological Factors, Including Alexithymia, in the Prediction of Cardiovascular Risk in HIV
Infected Patients: Results of a Cohort Study. PLoS ONE 8(1): e54555. doi:10.1371/journal.pone.0054555
Editor: Gerard Pasterkamp, University Medical Center Utrecht, The Netherlands
Received September 8, 2012; Accepted December 12, 2012; Published January 22, 2013
Copyright: 2013 Parruti et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This work was partly supported by a grant by the Fondazione onlus Camillo De Lellis Per lInnovazione e la Ricerca in Medicina, Pescara, Italy. No
additional external funding was received for this study. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of
the manuscript.
Competing Interests: Lamberto Manzoli is a PLOS ONE Editorial Board member. This does not alter the authors adherence to all the PLOS ONE policies on
sharing data and materials.The other authors have declared that no competing interests exist.
* E-mail: parruti@tin.it
. These authors contributed equally to this work.

metabolism, dyslipidemias and changes in body fat distribution


[9,10]. As compared with uninfected controls, increased intimamedia thickness of carotid arteries (c-IMT) and faster progression
of atheromasic lesions have been more frequently observed in
HIV-infected patients [1114], and an increased risk of myocardial infarction (MI) and other vascular events during continual
HAART has been conclusively demonstrated [15,16].
So far, preventive strategies have focused on modifiable
traditional risk factors for CVD [17]. Although the link between
psychological factors, such as depression, Type D personality
(Distressed Personality or Type D) and alexithymia, and athero-

Introduction
HIV-infected individuals are known to be at higher risk of
cardiovascular disease (CVD) than the general population [1,2].
HIV infection per se has been associated with imbalance of
inflammatory cytokines, endothelial dysfunction [3,4], hypercoagulability states [5,6] and vascular damage [7,8]. The sharp decline
of HIV associated morbidity and mortality in the era of Highly
Active Antiretroviral Therapy (HAART) was somewhat counterbalanced by the emergence of a number of metabolic derangements, including insulin resistance, frank abnormalities of glucose

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Alexithymia and Cardiovascular Risk in HIV

At the baseline visit, each patient agreeing to participate


underwent an in-depth assessment, including a structured
interview covering socio-demographic characteristics, HIV disease
history, presence of other comorbid conditions, health-related
behaviors, smoking status, cardiovascular risk factors, including
diabetes [33], medication exposure, and family or personal history
of vascular events (acute myocardial infarction (AMI), Transient
Ischemic Attack (TIA) or stroke). The 10-year cardiovascular risk
was assessed using the Framingham risk score (FRS) model,
recommended by NCEP (National Cholesterol Education Program), as accessed at http://hp2010.nhlbihin.net/atpiii/
calculator.asp [34].
AIDS-defining events, HCV and/or HBV coinfection(s), other
relevant comorbid condition(s), concomitant medications, duration of HIV infection, duration of HIV treatment, Nadir and
current CD4 T-cell Lymphocyte counts, HIV RNA levels at
diagnosis and at enrollment, use of Tenofovir (TDF) and third
antiretroviral drug (LPV/r, ATV/r, other boosted PIs, EFV,
NVP) were also recorded.
Additional information is provided as online supplemental
material (Methods S1).

sclerosis or vascular events has been repeatedly evaluated in


patients with heart diseases and in the general population, it has
been poorly examined in the HIV-infected population [1821].
Type D consists of two traits: negative affectivity (NA), the
tendency of an individual to experience negative emotions, and
social inhibition (SI), the tendency to feel discomfort in social
interactions, to exhibit a lack of social poise, and to avoid
confrontation. Alexithymia is a multi-trait personality construct
characterized by a deficiency in the cognitive processing of
emotions, namely, difficulties in identifying and communicating
emotions, and externally-oriented thinking. These characteristics
reflect a disruption in the conscious experience of emotions.
Psychological factors may be related to atherosclerosis and other
vascular events through their association with behavioral risk
factors, such as smoking, physical activity, diet and abdominal
obesity [22,23]. They may also directly affect biological processes
by multiple pathways, such as inflammation [24], cardiovascular
reactivity [25], endothelial injury [26,27], platelet activation
[28,29] and autonomic dysfunction [30,31], whereby psychological factors may play both a primary and a secondary pathogenetic
role [32].
For this reason, the contextual evaluation of both psychological
and traditional cardiovascular risk factors may represent a useful
widening of the investigation of vascular risk also in the HIV
infected population. In 2007, we therefore designed a single center
cohort study, to evaluate the role of psychological factors,
including alexithymia, Type D and depressive symptoms, in
parallel with several traditional predictors of increased c-IMT,
Carotid Plaque(s) (CPs) and ensuing vascular events in HIVinfected patients. Here we report the results of baseline evaluation
and the first two-year follow-up, indicating that the alexithymic
trait, characterized by an impaired cognitive processing of
emotional stimuli, may be a relevant, previously unraveled,
predictor of CVD and vascular events in this setting.

Definition of the Main Outcomes


The main outcomes of our investigation were: (1) c-IMT
assessed as a continuous variable; (2) presence of CPs at baseline;
(3) vascular events during follow-up (every 3 months), including
TIA or stroke, acute coronary syndrome (unstable Angina, nonST Elevation MI and STEMI) and myocardial or other organ
infarctions. All ultrasonographic scannings of carotid arteries of
the short and long axis were performed by the same certified
operator [35,36]. Vascular events were actively searched in the
cohort. They were positively assessed at each follow-up visit by the
assisting physicians and recorded in the study dataset when
appropriate, after review of clinical, laboratory and imaging data
supporting diagnoses of each vascular event. Records of all
patients dying during follow-up were also reviewed before
inclusion in the dataset. Finally, in order to avoid unnecessary
data censoring, as of March 20th, 2012, all patients not completing
their last follow-up visit (n = 38) were interviewed by phone, to
assess the possibility of late vascular events. Additional information
is provided in the online supplemental material (Methods S1).

Methods
Study Design
The study included a cross-sectional analysis of the baseline data
to evaluate the predictors of increased c-IMT and CPs, and a
prospective cohort analysis to explore the determinants of
cardiovascular events during a 5-year follow-up.

Definitions and Measures of the Psychological Constructs

Demographic, Clinical and Viro-immunological


Characterization of the Sample

The three psychological constructs were assessed contextually


by the same operator within a single interview. Depression
symptoms were investigated through the Beck Depression
Inventory II (BDI-II) [37]. Type D is a relatively new construct
characterized by 2 global personality traits: negative affectivity
(NA) and social inhibition (SI) [38,39]. This personality trait was
assessed with the Italian version of the 14-item DS14, consisting of
2 7-item subscales for NA and SI [39]. Alexithymia is a disorder of
the regulatory mechanisms of emotional and cognitive processing,
characterized by the following impairments: difficulty in differentiating feelings and distinguishing them from bodily sensations and
emotional arousal (DIF), difficulty in describing feelings to others
(DDF), and an externally oriented way of thinking (EOT) [40,41].
We used the Italian version of the TAS-20 (Toronto Alexithymia
Scale), universally employed for the alexithymia construct
worldwide [41]. Additional information is provided in the online
supplemental material (Methods S1).

Inclusion criteria were: treated or untreated confirmed chronic


HIV infection; age $18 y; any CD4 T-cell counts and HIV
viremia; absence of acute opportunistic infections, malignancy or
pregnancy at the time of enrollment and subsequent study
procedures; sufficient knowledge of the Italian language to
undergo psychological profiling; willingness and ability to provide
written informed consent. All consecutive HIV infected patients
aged 18 y or more, attending the Outpatient Clinics of the
Infectious Disease Unit of Pescara General Hospital, Italy, were
offered participation at their first access. The study psychologist
was on duty in most of the days when HIV outpatients were cared
for and he was the only staff member authorized to perform study
presentation and psychological tests. Therefore, patients were
offered participation in the study (psychological profiling and cIMT measurements) only when the psychologist was present. On
purpose accesses for participants were kept to a minimum, study
procedures being performed at one of the next scheduled visits
whenever possible. Laboratory measurements were obtained at
accesses for either study procedure.
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Alexithymia and Cardiovascular Risk in HIV

Figure 1. Eligibility Flow-Chart.


doi:10.1371/journal.pone.0054555.g001

known association with IMT, and including other eventually


significant variables, which were selected using a stepwise forward
process (including in model fitting all variables that were
significant at a 0.10 level in univariate analyses). Each covariate
was tested in its original form or transformed if needed. In
addition, each variable included was tested for multicollinearity,
for potential interaction and/or quadratic/cubic terms. We found
only total and LDL cholesterol to be collinear and chose to include
total cholesterol. For continuous covariates for which a defined
threshold has been indicated in the literature (i.e. TAS-20 score
$50), we tested the inclusion of both the continuous and
categorical form, and selected the one that was included in the
model with highest pseudo or adjusted R-squared values. The
procedures to assess the validity of the logistic and linear models

Statistical Analysis - Cross-sectional Analysis of Baseline


Data
Both multivariable linear and logistic regression analyses were
used to evaluate potential independent predictors of increased cIMT of carotid arteries and the presence of CPs. The dependent
variable was IM thickening as measured by IMT as a continuous
variable in the linear models and the presence of plaque(s) as a
dichotomic variable in the logistic models. In linear regression
analysis, the dependent variable was the inverse of IMT, which
was transformed because of its skewed distribution (ShapiroWilk).
We defined the regression models including a priori potential
confounders (age, gender, BMI, smoking, hypertension, diabetes,
one among total cholesterol and LDL-cholesterol, physical
activity, alcohol/drug abuse, educational level, presence of
psychiatric disorders and infection duration), because of their

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January 2013 | Volume 8 | Issue 1 | e54555

Alexithymia and Cardiovascular Risk in HIV

Table 1. Clinical, behavioral and socio-demographic


characteristics of the final sample (n = 201).

Table 1. Cont.

Category
Category
Age, mean (SD)

Efavirenz, n (%)
45.1 (10.1)

Gender

44 (21.9)

PIs, n (%)

91 (45.3)

Lopinavir, n (%)

27 (13.4)

Male, n (%)

153 (76.1)

Atazanavir, n (%)

37 (18.4)

Duration of HIV infection, yr mean (SD)

5.2 (4.4)

Other PIs, n (%)

31 (15.6)

HCV co-infection, n (%)

54 (26.9)

AIDS diagnosis, n (%)

76 (37.8)

HAART-treated, n (%)

160 (80)

Duration of HAART, yr, mean (SD)

5.1 (4.3)

Other drug(s), $1, n (%)

89 (59.8)

Nadir CD4 T-cell counts, mean (SD)

234 (181)

CD4 T-cell counts at baseline, mean (SD)

499 (283)

HIV viremia, undetectable at baseline, n (%)

120 (67.0)

Body Mass Index, mean (SD)

24.20 (3.82)

Hypertension, any level, treated or not, n (%)

53 (26.4)

Lipodystrophy, any type, n (%)

91 (45.3)

doi:10.1371/journal.pone.0054555.t001

are described in detail in the online supplemental material


(Methods S1).
For both linear and logistic models, all variables were tested for
inclusion and all variables that were not included into the final
models were not significant. Also, we tried to limit as much as
possible the number of covariates included in the final model to
avoid overfitting, and among the non-significant variables we left
inside the final model those that were associated with the highest
increase in model pseudo or adjusted R-squared, or that changed
the significant coefficients by more than 10%.
The results of the logistic analysis are presented as odds ratio
(OR) and 95% confidence limits whereas the results of the linear
regression analysis are presented as beta-coefficients, their
standard errors and standardized coefficients in order to quantify
the relative contribution of each covariate to the prediction of
IMT.

Framingham Risk Score, n (%)


010

149 (74.1)

1020

41 (20.4)

.20

11 (5.5)

Total Cholesterol, mmol/L, mean (SD)

5.0 (1.54)

Triglycerides, mmol/L, mean (SD)

1.94 (1.40)

HDL Cholesterol, mmol/L, mean (SD)

1.07 (0.34)

Statistical Analysis Survival Analysis of Follow-up Data

Fasting plasma glucose, mmol/L

5.15 (1.43)

Diabetes, n(%)

36 (17.9)

Intima Media Thickness, mm, mean (SD)

0.57 (0.22)

Cox proportional hazards analysis was used to calculate the


adjusted relative hazards of a vascular event by each variable.
Stochastic level of entry into the model was set at 0.10, and
interaction terms were explored for all variables in the final model.
A minimum events-to-variable ratio of 10 was maintained in
multivariate modeling to avoid overfitting, and Schoenfelds test
was performed to check the validity of proportional hazards
assumption [42]. We forced to entry all variables that were
significantly (or border line) associated with increased c-IMT and
CPs in the linear and logistic regression models, respectively. As
for the latter models, all variables were tested for inclusion and all
variables that were not included into the final Cox model were not
significant. Kaplan-Meier survival analysis was used to examine
the association between a TAS-20 score $50 and other significant
variables and vascular event. The validity of constant incidence
ratios over the follow-up was checked using Nelson-Aalen
cumulative hazard estimates [43].
In all multivariate analyses, less than 5% of the participants had
missing data, thus no missing data imputation technique was
adopted. Statistical significance was defined as a two-sided pvalue,0.05 for all analyses, which were performed using STATA
10.1 (Stata Corp., College Station, TX, U.S.A., 2007).

Presence of carotid plaque ($1.5 mm focal thickening), 59 (29.4)


n (%)
Alexithymia TAS-20 score, n (%)
2049

116 (57.7)

5060

48 (23.8)

$61

37 (18.5)

Alexithymia TAS-20$50, n (%)

85 (42.3)

Alexithymia TAS-20$61, n (%)

37 (18.5)

Type D Personality, n (%)

68 (34.2)

Beck Depression Inventory, $17, n (%)

56 (27.9)

Current Smoking, n (%)

113 (56.2)

Regular Sport practice, n (%)

70 (35)

Employed, n (%)

138 (69)

Married, n (%)

84 (41.8)

Psychiatric disorder, n (%)

27 (13.4)

Active drug abuse, n (%)

21 (10.5)

Educational level, n (%)


High

48 (23.9)

Ethics Statement

Medium

77 (38.3)

Low

76 (37.8)

The study protocol was set up and filed for approval by the local
Ethical Committee (Comitato etico per la Sperimentazione
Clinica dei Farmaci ASL di Pescara, http://www.
comitatoeticopescara.it/statuto.html) and Health District Authorities early in 2007. The final approval (authorization nu 943) was
granted on August 28th, 2008. Patients were enrolled and followed
from April 2007 through March, 2012. Informed consent was

Drug use
Tenofovir, n (%)

136 (67.7)

NNRTI, n (%)

68 (33.8)

Nevirapine, n (%)

26 (12.9)

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Alexithymia and Cardiovascular Risk in HIV

Table 2. Intima Media Thickness (IMT) in the sample (n = 201),


according to selected variables.

n.

Mean IMT SD

Age class

Table 2. Cont.

P (Rho)*

No

,0.001
(0.35)

n.

Mean IMT SD

110

0.53

0.15

Framingham Risk Score

,0.001
(0.28)

Age ,50 y

140

0.53

0.19

09

144

0.53

0.16

Age 5064 y

53

0.67

0.25

1020

46

0.65

0.28

Age $65 y

0.76

0.29

.20

11

0.78

0.43

,5.17

122

0.53

0.15

5.176.18

47

0.61

0.29

$6.2

32

0.67

0.29

Gender

0.7

Male

153

0.56

0.03

Female

48

0.58

0.02

Duration of HIV infection

Total Cholesterol, mmol/L

0.01

0.003 (0.21)

,10 y

64

0.52

0.17

Triglycerides, mmol/L

$10 y

136

0.60

0.24

#1.69

107

0.55

0.22

.1.69

92

0.60

0.22

HCV co-infection

0.06

0.17

Yes

54

0.53

0.14

HDL Cholesterol, mmol/L

No

147

0.59

0.24

,1.03

103

0.54

0.15

1.031.52

71

0.63

0.29

Yes

76

0.62

0.27

$1.55

21

0.57

0.18

No

125

0.55

0.18

#6.11

171

0.56

0.20

26

0.67

0.35

Yes

36

0.62

0.29

165

0.56

0.20

AIDS diagnosis

0.025

HAART
Treated

160

0.60

0.23

.6.11

Untreated

40

0.49

0.13

Diabetes

Duration of HAART

0.1 (0.12)

Fasting plasma glucose, mmol/L


0.008

0.020 (0.16)

0.03

0.15

Nave

37

0.49

0.13

No

,1 y

11

0.55

0.18

Alexithymia TAS-20 score

17 y

87

0.59

0.23

2050

121

0.54

0.16

.7 y

66

0.60

0.25

5160

42

0.62

0.26

$61

38

0.64

0.31

Other drug(s)

0.030

0.046 (0.15)

$1

89

0.62

0.25

Alexithymia TAS-20$50

None

60

0.53

0.16

Yes

85

0.65

0.30

No

116

0.53

0.13

Nadir CD4 T-cell count, cell/mmc

0.4 (20.05)

,0.001

,100

56

0.60

0.27

Alexithymia TAS-20$61

100250

59

0.56

0.14

Yes

37

0.64

0.31

.250

82

0.58

0.24

No

164

0.56

0.20

CD4 T-cell count at baseline, cell/mmc


,250

0.6 (0.03)
36

0.55

Yes

68

0.62

0.24

131

0.55

0.021

$17

56

0.54

0.15

,17

145

0.59

0.24

Current smoking

113

0.58

0.26

Former or never smoking

88

0.56

0.16

80

0.57

0.22

No

83

0.59

0.24

Depression (BDI-II)

HIV viremia

0.2
120
59

0.60 0.55

0.24 0.19
0.3 (0.07)

,20

12

0.58

0.23

2025

115

0.57

0.24

2630

60

0.59

0.19

.30

14

0.56

0.17

Hypertension
Any level, treated or not

53

0.64

0.27

Normotensive

148

0.55

0.20

Lipodystrophy

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0.15

Yes

70

0.54

0.16

No

130

0.59

0.25

Employed

138

0.56

0.18

Unemployed

62

0.61

0.29

84

0.58

0.19

Occupation

0.001
0.63

0.5

Sport practice

0.007

91

0.22

Smoking

Body Mass Index, kg/m2

Any type

0.12

0.17

.500

Undetectable Detectable

0.06

Type D Personality (DS-14)

250500

0.09

Familial status

0.28

Married

P (Rho)*

0.9

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Alexithymia and Cardiovascular Risk in HIV

Table 3. Characteristics of the sample according to the


presence of atherosclerotic plaque (IMTmax $1.5 mm).

Table 2. Cont.

n.

Mean IMT SD

117

0.57

0.24

(n = 59)

(n = 142)

Yes

27

0.56

0.18

Mean age in years mean(SD)

51.9 (9.4)

41.3 (9.0)

,0.001

No

174

0.58

0.23

Male gender, %

81.4

74.0

0.3

Duration of HIV infection, y, mean (SD)

15.7 (7.3)

12.2 (7.2)

0.002

Yes

21

0.54

0.13

HCV co-infection, %

28.8

26.1

0.7

No

180

0.58

0.23

AIDS diagnosis, %

50.9

32.4

0.014

Treated with HAART, %

88.1

76.6

0.06
0.003

Not married
Psychiatric disorder

P (Rho)*
Plaque
0.7

Active drug abuse

0.4

Educational level

0.5 (0.04)

No
Plaque

p*

High

76

0.57

0.23

Duration of HAART, y (SD)

6.5 (4.4)

4.6 (4.2)

Medium

77

0.57

0.23

Other drug(s), %**

79.6

51.4

0.001

Low

48

0.58

0.20

Nadir CD4 T-cell count, cell/mmc (SD)

197 (180)

250 (180)

0.06

CD4 T-cell count at baseline, cell/mmc (SD) 498 (273)

500 (288)

0.9

Tenofovir, Yes

136

0.57

0.24

HIV viremia, detectable, %

33.6

0.8

Tenofovir, No

65

0.58

0.19

NNRTI, Yes

68

0.60

0.23

NNRTI, No

133

0.56

0.22

Nevirapine, Yes

26

0.63

0.21

Nevirapine, No

175

0.56

0.22

Efavirenz, Yes

44

0.56

0.22

Efavirenz, No

157

0.58

0.23

PIs, Yes

91

0.59

0.24

PIs, No

110

0.56

0.21

Lopinavir, Yes

27

0.56

0.16

Lopinavir, No

174

0.58

0.23

Atazanavir, Yes

37

0.54

0.16

Atazanavir, No

164

0.58

0.23

Other PIs, Yes

31

0.63

0.32

Other PIs, No

168

0.57

0.20

Drug use
0.8

0.3

0.13

0.7

0.3

31.6

Body mass index, Kg/m , mean (SD)

24.53

24.10

0.4

Hypertension, %

45.8

18.3

,0.001

Lipodystrophy, %

66.1

36.6

,0.001

Framingham Risk Score mean (SD)

12.4 (8.3)

4.5 (5.2)

,0.001

Total cholesterol, mmol/L mean (SD)

5.33 (1.53) 4.88 (1.53) 0.06

HDL-c, mmol/L mean (SD)

1.1 (0.35)

Triglycerides, mmol/L mean (SD)

2.41 (1.96) 1.74 (1.03) 0.002

1.10 (0.33) 0.11

Fasting plasma glucose, mmol/L mean (SD) 5.59 (1.34) 4.97 (1.43) 0.005
Diagnosis of Diabetes, %

0.7

30.5

12.7

Alexithymia
Mean TAS-20 score mean (SD)

0.3

0.17

*p-values of the comparison between groups (categorical variables: chi-squared


test; continuous variables: Kruskal-Wallis test). For continuous variables only,
the Spearman Rho of the correlation between IMT and the variable in its
continuous form has been reported in brackets.
doi:10.1371/journal.pone.0054555.t002

signed by patients at enrollment, both to undergo study


investigations and for anonymised publishing of data.

52.5 (14.3) 45.2 (13.6) ,0.001

TAS-20$50, %

62.7

33.8

,0.001

TAS-20$61, %

33.9

12.6

,0.001

Depression BDI score .17, %

33.9

25.4

0.2

Type D Personality, %

37.3

32.9

0.6

Gainful employment, %

61.0

72.3

0.1

Smoker, %

67.8

51.4

0.03

Sport practice, %

30.5

36.9

0.4

Married, %

44.1

40.9

0.7

Active drug abuse, %

11.9

9.9

0.7

Psychiatric disorders, %

20.3

10.6

0.06

50.8

32.3

Educational level, %
Low

0.04

Results

Medium

32.2

40.9

Study Sample

High

20.8

26.7

The initial cohort screened for eligibility to participate in the


study consisted of 298 patients (Figure 1). Fourteen HIV-infected
patients visiting occasionally our Center were not offered
participation. Fifteen more patients were AIDS presenters with
severe clinical deterioration (n = 10) or chronic HIV patients with
hematological or neoplastic diseases (n = 5); similarly these patients
were not offered participation. Eight patients were excluded due to
linguistic barriers; 11 patients were not included as they reported
previous cardiovascular events; finally, a priori refusal of the initial
interview was expressed by 17 patients.
During the enrollment period, 241 eligible patients accepted the
initial interview and 232 also provided the informed consent. Of
them, 224 (96.6%) attended IMT measurements; 205 (88.4%)
psychological testing; 201 (86.6%) both procedures and could thus

Therapy
64.4

69.0

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0.003

Tenofovir, %

0.5

NNRTI, %

40.7

31.0

0.2

Nevirapine, %

22.0

9.2

0.01

Efavirenz, %

18.6

23.2

0.5

PIs, %

44.1

45.8

0.8

Lopinavir, %

13.6

13.4

0.9

Atazanavir, %

11.9

21.1

0.12

Other PIs, %

22.0

12.9

0.10

*Kruskal-Wallis test for continuous variables; chi-squared test for categorical


ones.
**59 missing values (21 among those with plaque; 38 among other
participants).
doi:10.1371/journal.pone.0054555.t003

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Alexithymia and Cardiovascular Risk in HIV

Table 4. Results from the multivariable regression model evaluating the association between the inverse of carotid Intima Media
Thickening (c-IMT) and various explanatory factors.

Regression coefficient

(95% CI)

Standardized coefficient

Age, 5-year increase

20.086

(20.129; 20.044)

,0.001

20.309

Male gender

0.030

(20.153; 0.213)

0.8

0.022

Body Mass Index, one unit increase

20.006

(20.030; 0.017)

0.6

20.040

Infection duration, years

20.008

(20.019; 0.004)

0.2

20.099

Hypertension

20.008

(20.211; 0.196)

0.9

20.005

Current smoking

20.076

(20.233; 0.082)

0.3

20.065

Diabetes mellitus

0.049

(20.168; 0.266)

0.7

0.032

Total cholesterol, 10 mg/dL increase

20.022

(20.035; 20.009)

0.001

20.225

Alexithymia TAS220 score $50

20.164

(20.322; 20.007)

0.032

20.141

CI = Confidence Interval. The final sample included 196 patients.


doi:10.1371/journal.pone.0054555.t004

to have at least one vascular carotid lesion meeting the primary


($1.5 mm) definition of CP [36].
As shown in Table 2, at univariate analyses increased c-IMT
was significantly associated with older age, duration of HIV
infection, AIDS diagnosis, treatment with HAART and its
duration, treatment with other drugs, hypertension, lipodystrophy,
higher Framingham risk score, total cholesterol, fasting plasma
glucose, TAS-20 score $50. As shown in Table 3, the presence of
CPs showed similar predictors: older age, duration of HIV
infection, AIDS diagnosis, HAART duration, therapy with other
drug(s), hypertension, lipodystrophy and higher Framingham
scores, smoking, higher triglycerides and fasting plasma glucose,
diabetes, alexithymia (at both cut-off values, TAS-20$50 and
$61), nevirapine as 3rd drug. Type D and a depression BDI score
$17 were not significantly associated with CPs, whereas an higher
educational level provided significant protection. A border-line
significance was observed for HAART therapy, higher cholesterol

be included in the multivariate analyses. The 31 patients with


missing values in one or more of the main outcomes were
unsuccessfully rescheduled for baseline visits more than once. To
exclude relevant selection biases, we compared the intention-totreat and per-protocol samples. In the total (n = 232) and final
(n = 201) samples, respectively, males were 74.1% and 76.0%; the
mean age was 44.569.9 y and 45.1610.1 y; drug abusers were
25.1% and 25.0%; heterosexuals 43.5% and 41.7%; homosexuals
28.9% and 31.3% and transfusions 2.5% and 2.0% (all p.0.05).
None of the other parameters, including AIDS diagnosis,
proportion of treatment nave patients and mean Nadir CD4 Tcell counts, were significantly different across samples.
The clinical, behavioral and socio-demographic characteristics
of the final sample (n = 201) are described in Table 1.

Predictors of c-IMT (Cross-sectional Analysis)


At baseline, among the 201 patients in the final sample, mean cIMT was 0.5760.22 mm. Fifty-nine patients (29.4%) were found

Table 5. Results from the logistic regression models predicting the presence of plaques (using diverse cutoffs for focal thickening)
with Alexithymia TAS-20 score cut-off $50.

IMTmax$1.5 mm

IMTmax$1.2 mm

IMTmax$1.0 mm

Variables

OR

(95% CI)*

OR

(95% CI)*

OR

(95% CI)*

Age, 5-year increase

1.72

(1.362.19)

,0.001

2.25

(1.732.93)

,0.001

2.03

(1.582.62)

,0.001

Male gender

2.24

(0.746.75)

0.15

2.12

(0.726.26)

0.17

1.93

(0.715.26)

0.2

Body Mass Index, 1 unit increase

0.99

(0.881.10)

0.8

1.02

(0.911.15)

0.7

0.96

(0.851.09)

0.5

Infection duration, 1-year increase

1.04

(0.981.10)

0.19

1.05

(0.991.12)

0.082

1.05

(0.991.11)

0.077

Hypertension

1.93

(0.784.82)

0.16

1.73

(0.674.46)

0.3

2.59

(0.917.35)

0.074

Current smoking

2.74

(1.166.44)

0.021

2.48

(1.045.92)

0.041

1.55

(0.663.63)

0.3
0.9

Diabetes mellitus

1.10

(0.373.23)

0.9

1.15

(0.373.55)

0.8

1.02

(0.323.23)

Total cholesterol, 10 mg/dL increase

1.10

(1.051.16)

,0.001

1.12

(1.071.18)

,0.001

1.12

(1.061.18)

,0.001

Alexithymia TAS-20 score $50

2.63

(1.175.89)

0.019

2.99

(1.316.83)

0.009

4.23

(1.869.61)

0.001

CI = Confidence Interval. OR = Odds Ratio.


*Based upon robust standard errors. Parameters of the models: (1.0 mm) n. of obs. = 196; Wald chi-squared = 66.4; HosmerLemeshow goodness of fit p = 0.27; area
under the receiving operator curve (ROC) = 0.87; (1.2 mm) n. of obs. = 196; Wald chi-squared = 61.9; HosmerLemeshow goodness of fit p = 0.68; area under the
receiving operator curve (ROC) = 0.87; (1.5 mm) n. of obs. = 196; Wald chi-squared = 44.1; HosmerLemeshow goodness of fit p = 0.23; area under the receiving operator
curve (ROC) = 0.84.
doi:10.1371/journal.pone.0054555.t005

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Alexithymia and Cardiovascular Risk in HIV

Table 6. Characteristics of the final sample according to the presence of vascular events.

Vascular

No

Events

Events

(n = 19)

(n = 182)

p*

Mean age, y, mean (SD)

54.1 (8.5)

44.2 (9.8)

,0.001

Male gender, %

9.8

8.3

0.8

Duration of HIV infection, y, mean (SD)

14.6 (7.3)

13.1 (7.4)

0.4

HCV co-infection, %

5.6

10.9

0.3

AIDS diagnosis, %

13.2

7.2

0.16

Treated with HAART, %

9.4

7.5

0.7

Duration of HAART, y, mean (SD)

5.7 (4.0)

5.1 (4.4)

0.6

Other drug(s), % **

11.2

5.0

0.2

Nadir CD4 T-cell count, cell/mmc mean (SD)

281 (244)

229 (173)

0.23

CD4 T-cell count at baseline, cell/mmc, mean (SD)

557 (317)

493 (280)

0.4

HIV viremia, detectable (%)

10.2

10.0

1.0

Body Mass Index mean (SD)

24.0 (3.2)

24.2 (3.9)

0.4

Lipodystrophy, %

13.2

6.4

0.1

Hypertension, %

13.2

8.1

0.3

Diagnosis of Diabetes, %

11.1

9.1

0.7

Fasting plasma glucose, mmol/L mean (SD)

5.3 (0.72)

5.1 (1.5)

0.8

Total cholesterol, mmol/L, mean (SD)

5.3 (1.6)

5.0 (1.5)

0.4

HDL-c, mmol/L, mean (SD)

1.1 (0.47)

1.1 (0.33)

0.7

Triglycerides, mmol/L, mean (SD)

1.94 (1.3)

1.93 (1.4)

1.0

Framingham Risk Score mean (SD)

13.8 (9.3)

6.1 (6.6)

,0.001

c-IMT, mm mean (SD)

0.76 (0.33)

0.55 (0.20)

,0.001

Presence of plaque ($1.5 mm), %

25.4

2.8

,0.001

Mean TAS-20 score mean (SD)

53.5 (14.0)

46.7 (14.0)

0.05

TAS $50, %

17.7

3.5

0.001

Depression BDI score.17, %

14.3

7.6

0.14

Type D Personality, %

11.8

7.6

0.30

Current smoking, %

12.4

5.7

0.1

Sport practice, %

5.7

11.5

0.2

Gainful employment, %

8.7

11.3

0.6

Alexithymia

Married, %

8.3

10.3

0.6

Active drug abuse, %

4.8

10.0

0.4

Psychiatric disorders, %

11.1

9.2

0.8

Low

52.6

36.3

0.16

Medium

31.6

39.0

0.5

High

15.8

24.7

0.4

Tenofovir, %

8.1

12.3

0.4

NNRTI, %

14.7

6.8

0.07

Nevirapine, %

19.2

8.0

0.07

Efavirenz, %

6.8

10.2

0.5

PIs, %

6.6

11.8

0.2

Lopinavir, %

7.4

9.8

0.7

Atazanavir, %

10.8

9.2

0.8

Other PIs, %

9.7

8.9

0.9

Educational level, %

Therapy

*Kruskal-Wallis test for continuous variables; chi-squared test for categorical ones.
doi:10.1371/journal.pone.0054555.t006

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January 2013 | Volume 8 | Issue 1 | e54555

Alexithymia and Cardiovascular Risk in HIV

430.5 person-years). The overall incidence of vascular events was


4.41 (95% CI: 2.666.89) per 100 person-years. Ninety-nine
patients (9.5%) had a vascular event during the follow-up: 6 AMI,
6 TIA, 5 strokes, and 2 other organ infarctions (one intestinal
infarction and 1 renal infarction). Deaths from any cause were 12;
of these, 4 (33.3%) were caused by cardiovascular events.
The distributions of all considered variables were compared in
patients with or without cardiovascular events (Table 6). At
univariate analyses, age, c-IMT, presence of plaque, Framingham
score and alexithymia score (both continuous or dichotomic) were
significantly associated with vascular events. Also, a border-line
significance was observed for smoking. All other factors were not
significantly associated with vascular events. Notably, the incidence of vascular events was 8.45 (95% CI: 4.7313.9) per 100
person-years in patients with TAS-20$50; 1.58 (95% CI: 0.43
4.05) per 100 person-years in patients with TAS,20.
In the Cox proportional hazards model, age (Hazard ratio, HR,
1.55, 95%CI: 1.192.02, p = 0.001), current smoking (3.87, 1.25
12.0, p = 0.019) and TAS-20$50 (5.58, 1.4421.6, p = 0.013) were
the only factors significantly associated with vascular events
(Table 7). The relationship between vascular events and
alexithymia is also apparent from the shape variation of the
Kaplan-Meier estimates of time to event (Figure 2).

Table 7. Results from the Cox proportional hazards


regression analyses predicting time to vascular events.

Hazard Ratio (95% CI)

Age, 5-year increase

1.55

(1.192.02)

0.001

Infection duration, 1-year increase

0.98

(0.911.05)

0.5

Hypertension

0.44

(0.131.50)

0.2

Current smoking

3.87

(1.2512.0)

0.019

Total cholesterol, 10 mg/dL increase

1.06

(0.981.14)

0.13

Alexithymia TAS-20 score $50 vs ,50

5.58

(1.4421.6)

0.013

doi:10.1371/journal.pone.0054555.t007

levels, lower Nadir CD4 T-cell counts, presence of psychiatric


disorders.
At multivariate analyses, only increasing age, total cholesterol,
current smoking and a TAS-20$50 remained significantly
associated with both cIMT (Table 4) and CPs (Table 5). Our
findings on CPs were similar in the logistic models using three
different thresholds for carotid plaque ($1.5 mm; $1.2 mm;
$1.0 mm), with the exception of current smoking, that was not
significant with the least conservative threshold for plaque
(1.0 mm). In particular, subjects with a TAS-20$50 consistently
showed an OR .2.5 of having a CP (p,0.01) with all thresholds
(Table 5). Even at the higher cut-off score for alexithymia (TAS20$61), the association between alexithymia and CPs remained
significant (p,0.02 whatever the c-IMTmax threshold for plaque;
data not shown). Notably, no other factor among those identified
in univariate analyses was independently associated with either
cIMT or CPs.

Discussion
Depression, Type D and alexithymia were found to be strongly
related to cardiovascular risk in several populations [4448], but
HIV patients were not yet considered. This cohort study
investigated for the first time the potential role of such
psychological traits, in addition to traditional cardiovascular risk
factors, in predicting CVD in the HIV population.
Despite an association between CVD and depression was
repeatedly documented, and several studies showed a role of
immune parameters in such a relationship, making its investigation
particularly interesting in the setting of HIV infection [49,50], we
observed a possible association between higher depression scores
and the presence of CPs in univariate models, but failed to

Predictors of Vascular Events (Follow-up Survival


Analysis)
The mean follow-up of the 201 patients undergoing both c-IMT
and psychological evaluations was 7826308 days (for a total of

Figure 2. Kaplan-Meier estimates of time to vascular events by alexithymia (TAS-20 score $50 versus TAS-20 score ,50).
doi:10.1371/journal.pone.0054555.g002

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Alexithymia and Cardiovascular Risk in HIV

demonstrate an independent association when contextually


evaluating the other psychological constructs.
Some prospective studies suggested a potential association of Type
D with hypercholesterolemia, hypertension, metabolic syndrome
and increased mortality rates in patients with established CVD [51
56]. As for depression, the association among Type D personality and
investigated outcomes was not confirmed in our cohort.
In contrast, we found that higher alexithymia scores were
associated with higher c-IMT, presence of CPs and vascular
events, both in univariate analyses and in all final multivariate
models. Indeed, several studies investigated the relationships
between alexithymia, cardiovascular risk factors, CVD and
cardiovascular mortality in the general population [44,45,57,58].
In particular, two large population-based studies linked the
alexithymic trait with a previous diagnosis of coronary heart
disease and subclinical atherosclerosis and, more recently, with
increased cardiovascular mortality [44,45]. The preliminary,
mechanistic explanation of such findings may be provided by
the fact that subjects with the alexithymic trait were shown to
suffer amplified and prolonged neurovegetative reactions to stress
stimuli, using models of skin-conductance response [59,60]. Such
investigations suggested that the alexithymic trait may disturb the
autonomic system and the pituitary-adrenal axis, leading to
increased neuroendocrine insult of the vasculature [44,60]. In
fact, in the HIV setting, the association between the alexithymic
trait and CVD risk is in line with the predictions of the cognitiveemotional interaction model [6165], according to which the high
prevalence of alexithymia in HIV may reflect the effects of the
virus on sub-cortical areas of the brain, involved in cognitive
emotional regulation and the relative autonomic responses
mediating vascular damage [6668].
An alternative explanation for the observed association between
alexithymia and CVD would be that alexithymic patients might
have an intrinsic higher risk of CVD simply because they more
frequently present traditional cardiovascular risk factors. For
instance, if subjects with alexithymia were more commonly
diabetics, hypertensive, obese and smokers, their higher risk of
CVD would not be caused by the psychological trait, but rather by
such well-known risk factors (a typical example of confounding).
Also, in this scenario, the co-inclusion of such factors and
alexithymia in multivariate analysis might have covered the
statistical significance of single risk factors due to a certain degree
of multicollinearity (which may also explain why we did not
observe a significant association between CVD and other wellknown CVD risk factors). However, in our sample alexithymic
patients were not significantly more hypertensive (p = 0.6), smokers
(p = 0.2) or obese (p = 0.2). They were older (48.3 y vs 42.8 y,
p,0.001), and more frequently diabetics (27.1% vs 11.2%,
p = 0.004). Nevertheless, when analyses were stratified by ageclass and diabetes, alexithymia remained significantly and strongly
associated with the presence of plaques as well as with vascular
events both in patients ,50 y and in non diabetics (see Table S1).
Our data would therefore suggest a true association between the
alexithymic trait and CVD risk in HIV patients, in agreement with the
above mentioned cognitive-emotional interaction model [6168].
Alexithymia may thus represent a novel and unexpected determinant
of accelerated atherothrombosis in the setting of HIV infection.
Importantly, in our sample 42.3% of the patients had a TAS-20
score $50; a prevalence of the alexithymic trait including borderline
cases that is nearly three times higher than in the general population
[69,70]. Such proportion rose to 70.4% in patients aged $55
(p = 0.002, data not shown). Thus, besides the relatively small sample
size and short follow-up, our data can only provide preliminary
findings, to be interpreted with caution, because the high prevalence

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of the alexithymic trait may partly reflect a secondary effect of HIVmediated vascular damage on such brain areas [66,71,72]. On the
other side, if the observed association will be confirmed, the high
prevalence of alexithymia in our sample may explain the high
incidence of vascular events that we observed in a relatively short
follow-up: approximately 10% of patients suffered a vascular event
(lethal in one third of cases), a remarkable and unexpected rate at the
time of cohort setting.
It is worth noting, in any case, that this is the first evaluation of
the prevalence of alexithymia in an unselected sample of HIV
patients. Notably, the alexithymic trait was not associated with
either current (p = 0.8) or Nadir CD4 T-cell counts (p = 0.9),
duration of HIV infection (p = 0.8), AIDS diagnosis (p = 0.5) or
baseline HIV viremia (p = 0.4, data not shown), suggesting either a
relation with behaviors at risk of getting HIV infection, such as
drug addiction [73], or with the early phases of HIV infection
[68]. Furthermore, data collected on a fraction (n = 70) of patients
in our sample, who were retested for psychological traits after a
mean of 18 months, revealed that alexithymic scores were only
minimally modified (data not shown), indicating a remarkable
stability of such a psychological phenotype over time, in line with
other reports in the general population [74].
The major strengths of our study are the accurate consecutive
enrolment of the study sample, the contextual evaluation of both
the psychological traits and c-IMT, each operated by a single
certified investigator, and the active follow-up for vascular events,
that allowed limiting data censoring to a minimum in the final
Coxs multivariate models. In addition to the limitations
mentioned above, shortcomings of the study are the single
experimental site and the inclusion of 95% of Caucasian subjects.
In conclusion, HIV alexithymic patients may be at a significantly
and persistently increased risk of both preclinical and clinically overt
vascular damage. Such a result is preliminary and require confirmation from studies with larger sample size and longer follow-up. In fact,
further research is strongly warranted: should our findings be
confirmed, they may pave the way to an array of additional
interventions to control cardiovascular disorders in the HIV
population.

Supporting Information
Table S1 Association between presence of plaque or
vascular events and alexithymia (TAS-20 score $50),
stratified by age class and diabetes.
(DOC)
Methods S1 Supplementary methods.

(DOC)

Acknowledgments
We are greatly indebted with nurses in the wards of the Infectious Disease
Unit of Pescara, in particular with Mrs. Angela Pisciella and Mrs. Teresa
Moschiano, who helped with patients enrolled in the study, and with the
staff of the Fondazione onlus Camillo De Lellis Per lInnovazione e la
Ricerca in Medicina, Pescara, Italy, for their invaluable and relentless
help.

Author Contributions
Conceived and designed the experiments: GP FV F. Santilli LM.
Performed the experiments: GP FV F. Sozio EM TU MT GC EP F.
Santilli PDS MCV. Analyzed the data: GP FV F. Santilli F. Sozio MF GC
LM. Contributed reagents/materials/analysis tools: GP FV EP LM. Wrote
the paper: GP FV EM TU MT GC EP F. Santilli MF LM.

10

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Alexithymia and Cardiovascular Risk in HIV

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